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Center for Substance Abuse Treatment. Substance Abuse Treatment: Group Therapy. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2005. (Treatment Improvement Protocol (TIP) Series, No. 41.)

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Substance Abuse Treatment: Group Therapy.

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2 Types of Groups Commonly Used in Substance Abuse Treatment

This chapter presents five models of groups used in substance abuse treatment, followed by three representative types of groups that do not fit neatly into categories, but that, nonetheless, have special significance in substance abuse treatment. Finally, groups that vary according to specific types of problems are considered. The purpose of the group, its principal characteristics, necessary leadership skills and styles, and typical techniques for these groups are described.

Overview

Introduction

Five Group Therapy Models

Psychoeducational Groups

Skills Development Groups

Cognitive–Behavioral Groups

Support Groups

Interpersonal Process Group Psychotherapy

Specialized Groups in Substance Abuse Treatment

Relapse Prevention

Communal and Culturally Specific Groups

Expressive Groups

Groups Focused on Specific Problems

Introduction

Substance abuse treatment professionals employ a variety of group treatment models to meet client needs during the multiphase process of recovery. A combination of group goals and methodology is the primary way to define the types of groups used. This TIP describes five group therapy models that are effective for substance abuse treatment:

  • Psychoeducational groups
  • Skills development groups
  • Cognitive–behavioral/problemsolving groups
  • Support groups
  • Interpersonal process groups

Each of the models has something unique to offer to certain populations; and in the hands of a skilled leader, each can provide powerful therapeutic experiences for group members. A model, however, has to be matched with the needs of the particular population being treated; the goals of a particular group’s treatment also are an important determinant of the model that is chosen.

This chapter describes the group’s purpose, principal characteristics, leadership requisites, and appropriate techniques for each type of group. Also discussed are three specialized types of groups that do not fit into the five model categories, but that function as unique entities in the substance abuse treatment field:

  • Relapse prevention treatment groups
  • Communal and culturally specific treatment groups
  • Expressive groups (including art therapy, dance, psychodrama)

Figure 2-1 lists some groups commonly used in substance abuse treatment and classifies them into the five‐model framework used in this TIP. This list of groups is by no means exhaustive, but it demonstrates the variety of groups found in substance abuse treatment settings.

Figure 2-1. Groups Used in Substance Abuse Treatment and Their Relation to Six Group Models

Group Types Group Model or Combination of Models
Skills Development Cognitive–Behavioral Therapy Interpersonal Process Support Specialized Group Psycho‐educational
Anger/feelings management
Skills‐building
Conflict resolution
Relapse prevention
12‐Step psychoeducational
Psychoeducational
Trauma (abuse, violence)
Early recovery
Substance abuse education
Spirituality‐based
Cultural
Psychodynamic
Ceremonial healing practices
Support
Family roles (psychoeducational)
Expressive therapy
Relaxation training
Meditation
Multiple‐family
Gender specific
Life skills training
Health and wellness
Cognitive–behavioral
Psychodrama
Adventure‐based
Marathon
Humanistic/existential
Source: Consensus Panel.

Occasionally, discussions in this TIP refer to the stages of change delineated by Prochaska and DiClemente (1984). They examined 18 psychological and behavioral theories of how change occurs, including the components of a biopsychosocial framework for understanding substance abuse. Their result was a continuum of six categories for understanding client motivation for changing substance abuse behavior. The six stages are:

  • Precontemplation. Clients are not thinking about changing substance abuse behavior and may not consider their substance abuse to be a problem.
  • Contemplation. Clients still use substances, but they begin to think about cutting back or quitting substance use.
  • Preparation. Clients still use substances, but intend to stop since they have recognized the advantages of quitting and the undesirable consequences of continued use. Planning for change begins.
  • Action. Clients choose a strategy for discontinuing substance use and begin to make the changes needed to carry out their plan. This period generally lasts 3–6 months.
  • Maintenance. Clients work to sustain abstinence and evade relapse. From this stage, some clients may exit substance use permanently.
  • Recurrence. Many clients will relapse and return to an earlier stage, but they may move quickly through the stages of change and may have gained new insights into problems that defeated their former attempts to quit substance abuse (such as unrealistic goals or frequenting places that trigger relapse).

For a detailed description of the stages of change, see TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment (Center for Substance Abuse Treatment [CSAT] 1999b ).

The client’s stage of change will dictate which group models and methods are appropriate at a particular time. If the group is composed of members in the action stage who have clearly identified themselves as substance dependent, the group will be conducted far differently from one composed of people who are in the precontemplative stage. Priorities change with time and experience, too. For example, a group of people with substance use disorders on their second day of abstinence is very different from a group with 1 or 2 years of sobriety.

Theoretical orientations also have a strong impact on the tasks the group is trying to accomplish, what the group leader observes and responds to in a group, and the types of interventions that the group leader will initiate. Before a group model is applied in treatment, the group leader and the treating institution should decide on the theoretical frameworks to be used, because each group model requires different actions on the part of the group leader. Since most treatment programs offer a variety of groups for substance abuse treatment, it is important that these models be consistent with clearly defined theoretical approaches.

In practice, however, groups can, and usually do, use more than one model, as shown in Figure 2-1. For example, a therapy group in an intensive early recovery treatment setting might combine elements of psychoeducation (to show how drugs have ravaged the individual’s life), skills development (to help the client maintain abstinence), and support (to teach individuals how to relate to other group members in an honest and open fashion). Therefore, the descriptions of the groups in this chapter are of ideal, pure forms that rarely stand alone in practice. It must be acknowledged, too, that the terms used to describe groups are not altogether clear‐cut and consistent. In different treatment settings, programs, and regions of the country, a term like “support group” may be used to refer to different types of treatment groups, including a relapse prevention group.

Despite such discrepancies between neat theory and untidy practice, little difficulty will arise if the group leader exercises sound clinical judgment regarding models and interventions to be used. One exception to this assurance, however, should be noted. Close adherence to the theory that dictates the way an interpersonal process group should be conducted has crucial implications for its success.

Five Group Models

Figure 2-2 summarizes the characteristics of five therapeutic group models used in substance abuse treatment. Variable factors include the focus of group attention, specificity of the group agenda, heterogeneity or homogeneity of group members, open‐ended or determinate duration of treatment, level of facilitator or leader activity, training required for the group leader, length of sessions, and preferred arrangement of the room.

Figure 2-2. Characteristics of Five Group Models Used in Substance Abuse Treatment

Group model Group/leader focus Specificity of the group agenda Heterogeneous or homogeneous Open‐ended/ determinate Level of facilitator activity
PsychoeducationalLeader focusedSpecificEitherEitherHigh
Skills development Leader focusedSpecificEitherEither (depending on topic)High
Cognitive–behavioralMixed/balanceEitherEitherEitherHigh
SupportGroup focusNonspecificEitherOpenLow to moderate
Interpersonal process Group focusNonspecificHeterogeneousOpenLow to moderate
Group model Level of facilitator activity Duration of treatment Length of session Space and arrangement Leader training
PsychoeducationalHighLimited by program requirements15 to 90 minutes Horseshoe or circleBasic
Skills development HighVariable45 to 90 minutesHorseshoe or circleBasic with some specialized training
Cognitive–behavioralHighVariable and open‐ended60 to 90 minutes CircleSpecialized training
SupportLow to moderateOpen‐ended45 to 90 minutesCircleSpecialized training with process‐ oriented skills
Interpersonal ProcessLow to moderateOpen‐ended1 to 2 hoursCircleSpecialized training in interpersonal process groups

Psychoeducational Groups

Psychoeducational groups are designed to educate clients about substance abuse, and related behaviors and consequences. This type of group presents structured, group‐specific content, often taught using videotapes, audiocassette, or lectures. Frequently, an experienced group leader will facilitate discussions of the material (Galanter et al. 1998). Psychoeducational groups provide information designed to have a direct application to clients’ lives—to instill self‐awareness, suggest options for growth and change, identify community resources that can assist clients in recovery, develop an understanding of the process of recovery, and prompt people using substances to take action on their own behalf, such as entering a treatment program. While psychoeducational groups may inform clients about psychological issues, they do not aim at intrapsychic change, though such individual changes in thinking and feeling often do occur.

Purpose. The major purpose of psychoeducational groups is expansion of awareness about the behavioral, medical, and psychological consequences of substance abuse. Another prime goal is to motivate the client to enter the recovery‐ready stage (Martin et al. 1996; Pfeiffer et al. 1991). Psychoeducational groups are provided to help clients incorporate information that will help them establish and maintain abstinence and guide them to more productive choices in their lives.

These groups also can be used to counteract clients’ denial about their substance abuse, increase their sense of commitment to continued treatment, effect changes in maladaptive behaviors (such as associating with people who actively use drugs), and supporting behaviors conducive to recovery. Additionally, they are useful in helping families understand substance abuse, its treatment, and resources available for the recovery process of family members.

Some of the contexts in which psychoeducational groups may be most useful are

  • Helping clients in the precontemplative or contemplative level of change to reframe the impact of drug use on their lives, develop an internal need to seek help, and discover avenues for change.
  • Helping clients in early recovery learn more about their disorders, recognize roadblocks to recovery, and deepen understanding of the path they will follow toward recovery.
  • Helping families understand the behavior of a person with substance use disorder in a way that allows them to support the individual in recovery and learn about their own needs for change.
  • Helping clients learn about other resources that can be helpful in recovery, such as meditation, relaxation training, anger management, spiritual development, and nutrition.

Principal characteristics. Psychoeducational groups generally teach clients that they need to learn to identify, avoid, and eventually master the specific internal states and external circumstances associated with substance abuse. The coping skills (such as anger management or the use of “I” statements) normally taught in a skills development group often accompany this learning.

Psychoeducational groups are considered a useful and necessary, but not sufficient, component of most treatment programs. For instance, psychoeducation might move clients in a precontemplative or perhaps contemplative stage to commit to treatment, including other forms of group therapy. For clients who enter treatment through a psychoeducational group, programs should have clear guidelines about when members of the group are ready for other types of group treatment.

Often, a psychoeducational group integrates skills development into its program. As part of a larger program, psychoeducational groups have been used to help clients reflect on their own behavior, learn new ways to confront problems, and increase their self‐esteem (La Salvia 1993).

Psychoeducational groups should work actively to engage participants in the group discussion and prompt them to relate what they are learning to their own substance abuse. To ignore group process issues will reduce the effectiveness of the psychoeducational component.

Psychoeducational groups are highly structured and often follow a manual or a preplanned curriculum. Group sessions generally are limited to set times, but need not be strictly limited. The instructor usually takes a very active role when leading the discussion. Even though psychoeducational groups have a format different from that of many of the other types of groups, they nevertheless should meet in a quiet and private place and take into account the same structural issues (for instance, seating arrangements) that matter in other groups.

As with any type of group, accommodations may need to be made for certain populations. Clients with cognitive disabilities, for example, may need special considerations. Psychoeducational groups also have been shown to be effective with clients with co‐occurring mental disorders, including clients with schizophrenia (Addington and el‐Guebaly 1998; Levy 1997; Pollack and Stuebben 1998). For more information on making accommodations for clients with disabilities, see TIP 29, Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities (CSAT 1998b ).

Leadership skills and styles. Leaders in psychoeducational groups primarily assume the roles of educator and facilitator. Still, they need to have the same core characteristics as other group therapy leaders: caring, warmth, genuineness, and positive regard for others.

Leaders also should possess knowledge and skills in three primary areas. First, they should understand basic group process—how people interact within a group. Subsets of this knowledge include how groups form and develop, how group dynamics influence an individual’s behavior in group, and how a leader affects group functioning. Second, leaders should understand interpersonal relationship dynamics, including how people relate to one another in group settings, how one individual can influence the behavior of others in group and some basic understanding of how to handle problematic behaviors in group (such as being withdrawn). Finally, psychoeducational group leaders need to have basic teaching skills. Such skills include organizing the content to be taught, planning for participant involvement in the learning process, and delivering information in a culturally relevant and meaningful way.

To help clients get the most out of psychoeducational sessions, leaders need basic counseling skills (such as active listening, clarifying, supporting, reflecting, attending) and a few advanced ones (such as confronting and terminating) (Brown 1998). It also helps to have leadership skills, such as helping the group get started in a session, managing (though not necessarily eliminating) conflict between group members, encouraging withdrawn group members to be more active, and making sure that all group members have a chance to participate. As the group unfolds, it is important that group leaders are nondogmatic in their dealings with group members. Finally, the group leader should have a firm grasp of material being communicated in the psychoeducational group.

During a session, the group leader should be mindful both of the group’s need and the specific needs of each member. The group leader will need to understand group member roles and how to manage problem clients. Except in unusual circumstances, efforts should be made to increase members’ comfort and to reduce anxiety in the group. Leaders will use a variety of resources to impart knowledge to the group, so each session also requires preparation and familiarization with the content to be delivered.

Group leaders should have ongoing training and formal supervision. Supervision benefits all group leaders of all levels of skill and training, as it helps to assure them that people in positions of authority are interested in their development and in their work. If direct supervision is not possible (as may be the case in remote, rural areas), then Internet discussions or regular telephone contact should be used.

Techniques. Techniques to conduct psychoeducational groups are concerned with (1) how information is presented, and (2) how to assist clients to incorporate learning so that it leads to productive behavior, improved thinking, and emotional change. Adults in the midst of crises in their lives are much more likely to learn through interaction and active exploration than they are through passive listening. As a result, it is the responsibility of the group leader to design learning experiences that actively engage the participants in the learning process. Four elements of active learning can help.

First, the leader should foster an environment that supports active participation in the group and discourages passive note taking. Accordingly, leader lecturing should be limited in duration and extent. The leader should concentrate instead on facilitating group discussion, especially among clients who are withdrawn and have little to say. They need support and understanding of the content before expressing their views. Techniques such as role playing, group problemsolving exercises, and structured experiences all foster active learning.

Second, the leader should encourage group participants to take responsibility for their learning rather than passing on that responsibility to the group leader. From the outset of the group, the leader can emphasize group self‐ownership by allowing members to participate in setting agreements and other group boundaries. The leader can emphasize member responsibility for honest, respectful interaction among all members and can de‐emphasize the leader role in determining group life.

Third, because many people have pronounced preferences for learning through a particular sense (hearing, sight, touch/movement), it is essential to use a variety of learning methods that call for different kinds of sensory experience. Excellent material on adapting instruction to learning styles is available through the Association for Supervision and Curriculum Development Web site, http://www.ASCD.org. To access the many articles and book chapters, enter “learning styles” into the search function and click the “Go” button.

Most people, at one time or another, have had unpleasant experiences in traditional, formal classroom environments. The resulting shame, rejection, and self‐deprecation strongly motivate people to avoid situations where these experiences might be brought back into awareness. Therefore it is critically important for the group leader to be sensitive to the anxiety that can be aroused if the client is placed in an environment that replicates a disturbing scene from the past. To allay some of these concerns, leaders can acknowledge the anxieties of participants, prevent all group participants from mocking others’ comments or ideas, and show sensitivity to the meaning of a participant’s withdrawal in the group. Overall, leaders should create an environment where participants who are having difficulty with the psychoeducational group process can express their concerns and receive support.

Fourth, people with alcoholism and other addictive disorders are known to have subtle, neuropsychological impairments in the early stage of abstinence. Verbal skills learned long ago (that is, crystallized intelligence) are not affected, but fluid intelligence, needed to learn some kinds of new information, is impaired. As a result, clients may seem more able to learn than they actually are. Therapists who are teaching new skills should be mindful of this difficulty.

Skills Development Groups

Most skills development groups operate from a cognitive–behavioral orientation, although counselors and therapists from a variety of orientations apply skills development techniques in their practice. Many skills development groups incorporate psychoeducational elements into the group process, though skills development may remain the primary goal of the group.

Purpose. Coping skills training groups (the most common type of skills development group) attempt to cultivate the skills people need to achieve and maintain abstinence. These skills may either be directly related to substance use (such as ways to refuse offers of drugs, avoid triggers for use, or cope with urges to use) or may apply to broader areas relevant to a client’s continued sobriety (such as ways to manage anger, solve problems, or relax).

Skills development groups typically emerge from a cognitive–behavioral theoretical approach that assumes that people with substance use disorders lack needed life skills. Clients who rely on substances of abuse as a method of coping with the world may never have learned important skills that others have, or they may have lost these abilities as the result of their substance abuse. Thus, the capacity to build new skills or relearn old ones is essential for recovery.

Since many of the skills that people with substance abuse problems need to develop are interpersonal in nature, group therapy becomes a natural treatment of choice for skills development. Members can practice with each other, see how different people use the same skills, and feel the positive reinforcement of a peer group (rather than that of a single professional) when they use skills effectively.

Principal characteristics. Because of the degree of individual variation in client needs, the particular skills taught to a client should depend on an assessment that takes into account individual characteristics, abilities, and background. The suitability of a client for a skills development group will depend on the unique needs of the individual along with the skills being taught. Most clients can benefit from developing or enhancing certain general skills, such as controlling powerful emotions or improving refusal skills when around people using alcohol or illicit drugs. Skills might also be highly specific to certain clients, such as relaxation training.

Skills development groups usually run for a limited number of sessions. The size of the group needs to be limited, with an ideal range of 8 to 10 participants (perhaps more, if a cofacilitator is present). The group has to be small enough for members to practice the skills being taught.

While skills development groups often incorporate elements of psychoeducation and support, the primary goal is on building or strengthening behavioral or cognitive resources to cope better in the environment. Psychoeducational groups tend to focus on developing an information base on which decisions can be made and action taken. Support groups, to be discussed later in this chapter, focus on providing the internal and environmental supports to sustain change. All are appropriate in substance abuse treatment. While a specific group may incorporate elements of two or more of these models, it is important to maintain focus on the overall goal of the group and link methodology to that goal.

Leadership skills and styles. In skills development groups, as in psychoeducation, leaders need basic group therapy knowledge and skills, such as understanding the ways that groups grow and evolve, knowledge of the patterns that show how people relate to one another in group, skills in fostering interaction among members, managing conflict that inevitably arises among members in a group environment, and helping clients take ownership for the group.

In addition, group leaders should know and be able to demonstrate the set of skills that the participants are trying to develop. Leaders also will need significant experience in modeling behavior and helping others learn discrete elements of behavior. Other general skills, such as sensitivity to what is going on in the room and cultural sensitivity to differences in the ways people approach issues like anger or assertiveness, also will be important. Depending on the skill being taught, there may be certain educational or certification requirements. For example, a nurse might be needed to teach specific health maintenance skills, or a trained facilitator may be needed to run certain meditation or relaxation groups.

Techniques. The specific techniques used in a skills development group will vary greatly depending on the skills being taught. (For more information on the techniques used in cognitive–behavioral coping skills training see chapter 4 of TIP 34, Brief Interventions and Brief Therapies for Substance AbuseTreatment [CSAT 1999a].)

It is useful to keep in mind that most skills, such as riding a bicycle or swimming, seem relatively simple, straightforward, and easy once incorporated into one’s repertoire of behavior. The process of learning and incorporating new skills, however, may be difficult, especially if the previous approach has been used for a long time. For instance, individuals who have been passive and nonassertive throughout life may have to struggle mightily to learn to stand up for themselves. As a consequence, it is crucial for leaders of skills development groups to be sensitive to the struggles of group participants, hold positive expectations for change, and not demean or shame individuals who seem overwhelmed by the task.

Furthermore, many behavioral changes that seem straightforward on the surface have powerful effects at deeper levels of psychological functioning. For instance, assertiveness may touch feelings of shame and unworthiness. Thus, new assertive competence may be incompatible with and overwhelmed by deep feelings of inadequacy and low self‐esteem. As a result, a client may learn a new behavior, but be unable to incorporate it into a repertoire of positive action. Counselors should not automatically assume, therefore, that a newly learned skill inevitably will translate into action. Feedback from participants on their progress since the last group is a good way to assess both learning and the incorporation of skills.

An often unstated and underrecognized difficulty in leading skills groups is that a leader teaching the same material week after week can become bored with the content. In due course, the boredom will creep into the teaching. To retain energy and teaching effectiveness, leaders can switch topics, or one leader can teach different topics over time. When feasible, it also may help to provide feedback to leaders by making video or audio recordings of their presentations.

Other specific techniques for skills development groups depend on the nature of the group, topic, and approach of the group leader. Before undertaking leadership of a skills development group, it is wise for the leader to have previously participated in the specific kind of skills development group to be led. Often special training programs are available for leaders of these kinds of groups.

Cognitive–Behavioral Groups

Cognitive–behavioral groups are a well‐established part of the substance abuse treatment field and are particularly appropriate in early recovery. The term “cognitive–behavioral therapy group” covers a wide range of formats informed by a variety of theoretical frameworks, but the common thread is cognitive restructuring as the basic methodology of change.

Purpose. Cognitive–behavioral groups conceptualize dependency as a learned behavior that is subject to modification through various interventions, including identification of conditioned stimuli associated with specific addictive behaviors, avoidance of such stimuli, development of enhanced contingency management strategies, and response‐desensitization (McAuliffe and Ch’ien 1986). The etiologies of dependency include neurobehavioral factors (Rawson et al. 1990), biopsychosocial (Nunes‐Dinis and Barth 1993; Wallace 1990), and the disease model (Miller and Chappel 1991), in which the key etiological determinants of dependency are genetic and physiological factors, ones that the person with dependency cannot control.

Cognitive–behavioral therapy groups work to change learned behavior by changing thinking patterns, beliefs, and perceptions. The groups also work to develop social networks that support continued abstinence so the person with dependency becomes aware of behaviors that may lead to relapse and develops strategies to continue in recovery (Matano et al. 1997).

Cognitive processes include a number of different psychological elements, such as thoughts, beliefs, decisions, opinions, and assumptions. A number of thoughts and beliefs are affected by an individual’s substance abuse and addiction. Some common errant beliefs of individuals entering recovery are

  • “I’m a failure.”
  • “I’m different.”
  • “I’m not strong enough to quit.”
  • “I’m unlovable.”
  • “I’m a (morally) bad person.” The word “morally” carries the implication of a “shame script” and feeling defective as a person. “Bad” alone refers more to behavior, or doing “bad things.”

Changing such cognitions and beliefs may lead to greater opportunities to maintain sobriety and live more productively.

Principal characteristics. In cognitive–behavioral groups for people who abuse substances, the group leader focuses on providing a structured environment within which group members can examine the behaviors, thoughts, and beliefs that lead to their maladaptive behavior. Treatment manuals—providing specific protocols for intervention techniques—may be helpful in some, though not all, cognitive–behavioral groups. In any case, most cognitive–behavioral groups emphasize structure, goal orientation, and a focus on immediate problems. Problemsolving groups often have a specific protocol that systematically builds problemsolving skills and resources.

One example is a model cognitive–behavioral group for women with posttraumatic stress disorder (PTSD) and substance abuse designed to

  • Educate clients about the two disorders
  • Promote self‐control skills to manage overwhelming emotions
  • Teach functional behaviors that may have deteriorated as a result of the disorders
  • Provide relapse prevention training (Najavits et al. 1996)

The group format is an important element of the model, given the importance of social support for PTSD and substance use disorders. In addition, group treatment is a well‐established, relatively low‐cost modality, so it can successfully reach a large number of clients. Some key characteristics of this program are that it

  • Uses a model designed for 24 sessions, in which 3–10 members meeting twice each week for 3 months in 90‐minute group meetings
  • Is early‐recovery–oriented, with a strong focus on coping skills to gain control over symptoms
  • Has homogeneous membership (for example, all women)
  • Includes a six‐session unit on relationships and themes, such as Safety and Self‐protection and Reaching Out for Help
  • Uses educational devices to promote rapid and sustained learning of material, such as visual aids, role preparation, memory improvement techniques, written summaries, review sessions, homework, and audiotapes of each session
  • Focuses on both disorders, with instruction on stages of recovery to motivate members to achieve abstinence and control over PTSD symptoms (Najavits et al. 1996)

Another cognitive–behavioral model was employed to reduce the anger that can trigger renewed use of cocaine among 59 men and 32 women diagnosed with cocaine dependence. The model assumed that angry responses are learned behavior that can be changed. Clients in the pilot program were taught to gauge their anger levels and to use anger management strategies like time‐outs and conflict resolution. During the 12 weeks of treatment, participants were able to reduce and control their anger more effectively than they had in the past, and these gains held at the follow‐up 3 months after treatment. Violent behavior also decreased significantly (Reilly and Shopshire 2000).

Leadership skills and styles. Cognitive–behavioral therapies encompass a variety of methodological approaches, all focused on changing cognition (beliefs, judgments, and perceptions) and the behavior that flows from it. Some approaches focus more on behavior, others on core beliefs, still others on developing problemsolving capabilities. Regardless of the particular focus, the group therapist conducting cognitive–behavioral groups should have a solid grounding in the broader theory of cognitive–behavioral therapy. This basis is the framework from which specific interventions can be drawn and implemented. Training in cognitive–behavioral theory is available in many workshops on counseling skills and in many alcohol and drug training programs for counselors. For instance, over a 2‐week period in 2002, the Rutgers Summer Schools of Alcohol and Drug Studies offered seven week‐long courses that concentrated specifically on cognitive counseling theory and methods. Many books are available on the theory of cognitive–behavioral therapy (Beck 1976; Ellis and MacLaren 1998; Glasser 2000; Leahy 1996) as well as self‐help manuals with a cognitive–behavioral focus (Burns 1999; Greenberger and Padesky 1995). See chapter 7 for more information about training sources.

The level of interaction by the therapist in cognitive–behavioral groups can vary from very directive and active to relatively nondirective and inactive. It also can vary from highly confrontational with group members to relatively nonconfrontational demeanor. Perhaps the most common leadership style in cognitive–behavioral groups is active engagement and a consistently directive orientation.

A cautionary note: In cognitive–behavioral groups, the leader may be tempted to become the expert in how to think, how to express that thinking behaviorally, and how to solve problems. It is important not to yield to such a temptation, but instead to allow group members to use the power of the group to develop their own capabilities in these areas.

Techniques. Specific techniques may vary based on the particular orientation of the leader, but in general, techniques include those which (1) teach group members about self‐destructive behavior and thinking that leads to maladaptive behavior, (2) focus on problemsolving and short‐ and long‐term goal setting, and (3) help clients monitor feelings and behavior, particularly those associated with drug use. More experienced leaders will have a wider range of specific techniques to engage participants and more comfort with a wider range of client needs and expectations.

An important element of conducting cognitive–behavioral groups is recognizing that behavioral change and intellectual insight gained in the group can be provocative and upsetting for clients with a poor sense of self, low self‐esteem, and fear of emotional and interpersonal inadequacy. As a result, resistance to change inevitably will occur as the group evolves and behavioral changes begin to become routine. Experienced leaders learn to recognize, respect, and work with the resistance instead of simply confronting it. Clinical supervision is quite beneficial in learning a variety of styles of working with resistance generated by growth and change.

Many specific approaches to cognitive–behavioral therapy, including rational emotive therapy (Ellis 1997), reality therapy (Glasser 1965) and the work of Aaron Beck and colleagues (1993), incorporate various techniques specific to each approach. Substance abuse treatment counselors may find it useful to explore these approaches for techniques appropriate to their specific client populations.

Support Groups

The widespread use of support groups in the substance abuse treatment field originated in the self‐help tradition in the field. These groups also have roots in the realization that significant lifestyle change is the long‐term goal in treatment and that support groups can play a major role in such life transitions. Self‐help groups share many of the tenets of support groups—unconditional acceptance, inward reflection, open and honest interpersonal interaction, and commitment to change. These groups attempt to help people with dependencies sustain abstinence without necessarily understanding the determinants of their dependence (Cooper 1987).

The focus of support groups can range from strong leader‐directed, problem‐focused groups in early recovery, which focus on achieving abstinence and managing day‐to‐day living, to group‐directed, emotionally and interpersonally focused groups in middle and later stages of recovery.

Purpose. Support groups bolster members’ efforts to develop and strengthen the ability to manage their thinking and emotions and to develop better interpersonal skills as they recover from substance abuse. Support group members also help each other with pragmatic concerns, such as maintaining abstinence and managing day‐to‐day living. These groups are also used to improve members’ general self‐esteem and self‐confidence. The group—or more often, the group leader—provides specific kinds of support, such as being sure to help clients avoid isolation and finding something positive to say about each participant’s contribution. In some programs, support groups might be considered process (therapy) groups, but the main interest of support groups is not in the intrapsychic world, and the goal is not character change. Process issues may be involved, but support groups are less complex, more direct, and narrower in focus than process groups.

Principal characteristics. Many people with substance use disorders avoid treatment because the treatment itself threatens to increase their anxiety. Because of support groups’ emphasis on emotional sustenance providing a safe environment, these groups are especially useful for apprehensive clients, indeed, for any client new to abstinence. The adjective “support” itself may be a way of destigmatizing the activity. For this reason, a “support” group may be more attractive to someone less committed to recovery than a “therapy” group.

Not all support groups, however, are intended just for clients new to recovery. Support groups can be found for all stages of treatment in all sorts of settings (inpatient, outpatient, continuing care, etc.). While a support group always will have a clearly stated purpose, the purpose varies according to its members’ motivation and stage of recovery. Many of these groups are open‐ended, with a changing population of members. As new clients move into a particular stage of recovery, they may join a support group appropriate for that stage until they are ready to move on again. Groups may continue indefinitely, with new members coming in and old members leaving, and occasionally, returning. Program differences will also alter how this type of group is used. A support group will be different in a 4‐ to 6‐week daily treatment program from the way it is used in a 1‐year treatment community.

In a support group, members typically talk about their current situation and recent problems that have arisen. Discussion usually focuses on the practical matters of staying abstinent; for example, ways to deal with legal issues or avoid places that tempt people to use substances. Group members are encouraged to share and discuss their common experiences.

Issues that do not specifically relate to the focus of the group are often considered extraneous, so discussion of them is limited. Support groups provide guidance through peer feedback, and group members generally require accountability from each other. The group leader, however, will try to minimize confrontation within the group so as to keep anxiety levels low. In cohesive, highly functioning support groups, member‐to‐member or leader‐to‐member confrontation does occur.

Support groups can work from a variety of theoretical positions. Many reflect the 12‐Step tradition in the substance abuse field, but other recovery tools, such as relapse prevention, can form the basis of a support group. Some support groups are based on theoretical frameworks such as cognitive therapies or spiritual paths. Programs may even design a support group by combining theories or philosophies.

Leadership skills and styles. Some support groups may be peer‐generated or peer‐led, but this TIP is mainly concerned with groups led by a trained, professional group leader. Support group leaders need a solid grounding in how groups grow and evolve and the ways in which people interact and change in groups. It is also critical that group leaders have a theoretical framework for counseling (such as cognitive–behavioral therapy) that informs their approach to support group development, the therapeutic goals for group members, the guidance of group members’ interactions, and the leader’s implementation of specific intervention methods.

Since the leader should help build connections between members and emphasize what they have in common, it is useful for the leader to have participated in a support group and to have been supervised in support group work before undertaking leadership of such a group. Training and supervision focused on how individuals develop psychologically, typical psychological conflicts, and the way these conflicts may appear in group therapy settings also may help the support group leader function more effectively, since such considerations help the leader understand individual members’ behavior in the group.

The leadership style for someone running a support group typically will be less directive than for psychoeducational, skills development, or cognitive–behavioral groups because the support group is generally group‐focused rather than leader‐focused. The leader’s primary role is to facilitate group discussion, helping group members share their experiences, grapple with their problems, and overcome difficult challenges. The group leader also provides positive reinforcement for group members, models appropriate interactions between individuals in the group, respects individual and group boundaries, and fosters open and honest communication in the group setting. In a most general way, the leader is active but not directive.

Techniques. The techniques of leading support groups vary with group goals and member needs. In general, leaders need to actively facilitate discussion among members, maintain appropriate group boundaries, help the group work though obstacles and conflicts, and provide acceptance of and regard for members. In a support group, the leader exercises the role of modeler of appropriate behaviors. In this way, the leader helps members grow and change.

Specific group techniques may appear to be less important for the leader of a support group, since the leader is usually less active in group direction and leadership. The techniques used in support groups, however, are simply less obvious.

Interventions, for example, are likely to be more interpretive and observational and less directive than in many other groups. The observations are generally limited to support for the progress of the group and facilitating supportive interaction among group members. The goal is not to provide insight to group members, but to facilitate the evolution of support within the group.

The support group leader is also responsible for monitoring each individual’s progress in group and ensuring that individuals are participating (in their own way) and benefiting from the group experience. Understanding some of the history of each person in the group, the leader also watches to see whether the group is providing each individual with emotional and interpersonal experiences that build success and skills that apply to life arenas outside the group. In addition to monitoring individuals in the group, the leader also monitors the progress of the group as a whole, making sure that group development proceeds through its predictable stages and does not become blocked at any stage of its evolution.

Finally the leader is responsible for recognizing interpersonal blocks or struggles between group members. It is not necessarily the responsibility of the leader to resolve these blocks, or even to point them out to group members, but to ensure that such struggles do not hinder the development of the group or any member of the group.

Interpersonal Process Group Psychotherapy

The interpersonal process group model for substance abuse treatment is grounded in an extensive body of theory (Brown 1985; Brown and Yalom 1977; Flores 1988; Flores and Mahon 1993; Khantzian et al. 1990; Matano and Yalom 1991; Vannicelli 1992; Washton 1992). Even this sharply defined area of process‐oriented group therapies is widely diverse. Psychodynamic group therapies can be thought of as a generic name encompassing several ways of looking at the dynamics that take place in groups. Originally, these dynamics were considered in Freudian psychoanalytic terms that placed a heavy emphasis on sexual and aggressive drives, and conflicts and attachments between parents and children. Over the past half century many researchers, such as Jung, Adler, Bion, Noreno, Rogers, Perls, Yalom, and others, expanded or changed the Freudian emphasis. As a result, current dynamic conceptualizations include heavy emphasis on the social nature of human attachment, rivalry and social hierarchies, and cultural and spiritual concerns (i.e., existential issues and questions of faith). This therapeutic approach focuses on healing by changing basic intrapsychic (within a person) or interpersonal (between people) psychological dynamics.

Thus, a student of process‐oriented group therapy, a group treatment approach that uses the process of the group as the primary change mechanism, soon learns that the way Bion (1961) taught group therapy will be far different from the way other recognized authorities, such as Wolf and Schwartz (1962), taught. These theorists in turn differ from the process‐orientation exemplified by Durkin (1964) or Glatzer (1969). The many theoretical variants differ in what they pay most of their attention to as group members interact.

Purpose. Interpersonal process groups use psychodynamics, or knowledge of the way people function psychologically, to promote change and healing. The psychodynamic approach recognizes that conflicting forces in the mind, some of which may be outside one’s awareness, determine a person’s behavior, whether healthy or unhealthy. Attachment to others is one of the contending forces. From a psychodynamic point of view, starting in early childhood, developmental issues are a key concern, as are environmental influences, to which certain people are particularly vulnerable because of their genetic and other biological characteristics. For those people who have been drawn to substance abuse, the interpersonal process group raises and re‐examines fundamental developmental issues. As faulty relationship patterns are perceived and identified, the group participant can begin to change dysfunctional, destructive patterns. The group member becomes increasingly able to form mutually satisfying relationships with other people, so alcohol and drugs lose much of their power and appeal.

Basic tenets of the psychodynamic approach include the following

  • Early experience affects later experience. Individuals bring their histories—personal, cultural, psychological, and spiritual—to therapy.
  • Sometimes perceptions distort reality. People often draw generalizations from their life experiences and apply the generalizations to the current environment, even when doing so is inappropriate or counterproductive. These “cognitive distortions” may serve to maintain habits people would otherwise like to change.
  • Psychological and cognitive processes outside awareness influence behavior. As clients become conscious of some formerly subconscious processes supporting a behavior they want to change, this information can be used to alter dysfunctional relationships.
  • Behaviors are chosen to adapt to situations and protect people from harm. A specific behavior is a person’s best effort to adapt to a particular situation given individual makeup, environment, and personal history. In a sense, people come to therapy because of their solutions, not their problems.

Within the interpersonal process model, the objects of interest are the here‐and‐now interactions among members. Of less importance is what happens outside the group or in the past. All therapists using a “process‐oriented group therapy” model continually monitor three dynamics:

  • The psychological functioning of each group member (intrapsychic dynamics)
  • The way people are relating to one another in the group setting (interpersonal dynamics)
  • How the group as a whole is functioning (group‐as‐a‐whole dynamics)

A group leader conducting an interpersonal process group, however, will tend to pay more attention to the interpersonal dynamics and concentrate less on each member’s individual psychological dynamics and the workings of the group as a whole. The section that follows includes illustrations (Figures 2-3 to 2‐6) of how groups might differ according to their focus on intrapsychic, interpersonal, and group‐as‐a‐whole dynamics.

The experienced group leader knows that the intervention chosen at any moment in the group will have an impact on all three dynamics and that a delicate balance must be struck in the attention given to each. A too‐intense focus on group members’ interaction, to the exclusion of attention to individual psychological needs or the needs of the group as a whole, blunts the effectiveness and relevance of group development.

Principal characteristics. Interpersonal process group therapy delves into major developmental issues, searching for patterns that contribute to addiction or interfere with recovery. The group becomes a microcosm of the way group members relate to people in their daily lives.

The Interpersonal Process Group Psychotherapy (IPGP) model links the abstinence‐based treatment approach with current psychological principles of treatment, while still remaining compatible with 12‐Step theory and practice. IPGP and substance abuse treatment both recognize that a person’s capacity for healthy interpersonal relationships supports solid recovery from substance abuse. IPGP is easy to understand and adapt because it is

  • Pragmatic. IPGP is a practical, nuts and bolts, hands‐on type of group treatment. It focuses on results, not abstract concepts and all‐encompassing theories, and its results‐oriented nature is especially satisfying to a population that needs some swift, positive outcomes. This feature is especially important during the early phases of treatment, when the window of opportunity for influencing clients is small and open only briefly.
  • Applicable. IPGP is a very adaptable model. Because it can so readily be modified, it can be applied in diverse sets of difficulties and under various circumstances. IPGP furnishes the group leader with a set of strategic tools that are easy to acquire and use. The IPGP model provides enough structure to prevent unproductive discussion. This is especially desirable because few will tolerate a passive group leader who waits for issues to evolve out of the flow of the group. On the other hand, many people who abuse substances will react negatively to a domineering or authoritarian leader. The IPGP model permits a group experience that is neither leader‐dependent nor leader‐centered. This generally egalitarian setting helps to reduce resistance.
  • Synergistic. IPGP and substance abuse treatment complement each other, reciprocally setting the scene for the establishment of the crucial components of effective treatment. The combination of IPGP and substance abuse treatment allows the client to experience treatment as emotionally supportive. This sparing of the client’s self‐image enables the client to identify positively with treatment and mutes any strong reactions to the counselor. Further, the combination of these two treatment approaches can ease the client’s handling of shame, the need to change aspects of self, the uncomfortable newness of the recovery period, and the therapeutic experience itself. Recovery can proceed as clients experience and re‐experience deep attachment dynamics and use the experience to craft major changes in character and behavior.

Leadership skills and styles. In interpersonal process groups, content is a secondary concern. Instead, leaders focus on the present, noticing signs of people recreating their past in what is going on between and among members of the group. If, for example, a person has a problem with anger, this problem eventually will be re‐enacted in the group. When an angry group member, “George,” explodes at “Charlie,” the therapist might say, “George, you seem to be having a strong response to Charlie right now. Who does Charlie remind you of? Does this feel familiar? Has anything like this happened to you before?”

On one hand, the interpersonal process group leader monitors how group members are relating, how each member is functioning psychologically or emotionally, and how the group as a whole is functioning. On the other hand, the interpersonal process group leader observes a variety of group dynamics, such as the stages of group development, how leadership is emerging in the group, the strengths each individual is bringing to the group as a whole, and how individual resistances to change are interacting with and influencing group functioning. The interventions of the leader are dependent on his or her perceptions of this mix.

Since the group leader’s theoretical persuasion, training, experience, and personality determine the level of intervention that takes priority at a particular time, it is rare to find two interpersonal process group leaders who will conduct a group in exactly the same manner. Even so, leaders in this type of group are not fonts of information, skill builders, problemsolving directors, or client boosters. In interpersonal process group therapy, the leader’s job is to promote and probe interactions that carry a point.

Most group leaders who apply a process‐oriented approach to group therapy with people who abuse substances recognize the theoretical influence of the Interactional Model (Yalom 1975). Yalom recommends an adaptable approach to group treatment, one that allows easily applied modifications across the continuum of the recovery needs of an individual who abuses substances. His model can be tightened (to have more structure) early in treatment and can subsequently be loosened (to relax structure) as more abstinent time passes, recovery is solidified, and the danger of relapse decreases.

Techniques. In practice, group leaders may use different models at various times, and may simultaneously influence more than one focus level at a time. For example, a group that focuses on changing the individual will also have an impact on the group’s interpersonal relations and the group‐as‐a‐whole. Groups will, however, have a general orientation that determines the focus the majority of the time. This focus is an entry point for the group leader, helping to provide direction when working with the group.

Specific techniques of the process group leader will vary, not only with the type of process group, but also with the developmental stage of the group. Early on in group development, process group leaders might consciously decide to be more or less active in the group life. They might also choose, based on the needs of the group, to make more or fewer interpretations of individual and group dynamics to the group as a whole. Likewise they might choose to show more warmth and supportiveness toward group members or take a more aloof position. For instance, in contrast to leading a support group, where the leader is likely to be unconditionally affirming, the process leader might make a conscious decision to allow clients to struggle to affirm themselves, rather than essentially doing it for them.

Such choices should be based on the needs of group members and the needs of the group as a whole, rather than the style that is most comfortable for the group leader. Obviously such tactical decisions require a high degree of understanding and insight about group dynamics and individual behavior. For this reason, almost all leaders of process groups will seek supervision and consultation to guide them in making the best tactical decisions in behalf of the group and its members.

Three group dynamics in practice

When deciding on a model for a substance abuse treatment group, programs need to consider their resources, the training and theoretical orientation of group leaders, and the needs and desires of clients in order to determine what approaches are feasible. While it is beyond the scope of this TIP to provide detailed instruction on how to run each of the different models of groups, the following figures do illustrate the basic differences among the psychodynamic emphases. Figure 2-3 describes an argument drawn from a problem‐focused group, which assists people in resolving a specific problem in their lives. (For additional information on this type of group, see the last section in this chapter. The reader also may refer to appendix B of TIP 34,a Brief Interventions and Brief Therapies for Substance Abuse [CSAT 1999a], for a list of resources that can provide further training and information about the theoretical orientations that influence these groups.)

Figure 2-3. Group Vignette: Joe’s Argument With His Roommate

Before the first meeting of a new problem‐focused group, Joe had been arguing with his roommate because the roommate had forgotten to pay the phone bill the previous month. Joe had told his roommate, Mike, that he might remember to pay the bills on time if he were not smoking pot every day, and they began an angry discussion about the roommate’s drug use. Joe tells the group that he wants to talk about his distrust of his roommate. Joe is not currently using drugs, but he is still struggling with attempts to control his drinking. Group members are generally supportive of Joe in his argument with his roommate. They express concern that he is living with someone who is actively using marijuana and other drugs. One group member, Jane, voices strong objections, however, to Joe’s lack of trust for his roommate. Jane is struggling with her own abuse of prescription tranquilizers, and she is typically rather quiet and anxious in group. Nonetheless, she attacks Joe verbally with uncharacteristic vehemence.
Source: Adapted from Flores 1997.

Individually focused groups

The individually focused group concentrates on individual members of the group and their distinctive internal cognitive and emotional processes. How the client interacts in the world at large is not on the agenda. The group instead strives to modify clients’ behavior. This model is used with a range of technical and theoretical approaches to group therapy, including cognitive therapy, expressive therapies, psychodrama, transactional analysis, redecision therapy, Gestalt, and reality therapy (see section below for further discussion of expressive therapies and psychodrama as well as the glossary in appendix D).

The group is conceived as an aggregate of individuals in which the group leader generally works sequentially with one group member at a time. While one individual’s issues are addressed, the other group members serve as observers, contributors, alter egos, or significant others. Generally, however, more than one group member will be involved in the conversation at one time, and all group members will be encouraged to actively help each other and learn from each other’s experiences. This model of group does not require a client to have insight into a problem but does require awareness of behavior and its immediate causes and consequences. Some individually oriented approaches will use group members in a structured/directive way, such as in a role‐playing exercise.

In the more cognitively oriented approaches, clients will focus on their behaviors in relation to thoughts. The more expressive form of individually oriented groups is particularly beneficial for clients who need a structured environment or have so much contained, powerful emotion that they need some creative way of releasing it.

Individually focused groups are useful to identify the first concrete steps in coping with substance abuse. They can help clients become more aware of behavior and its causes, and at the same time, they increase the client’s range of options as to how to behave. The ideal end result is the client’s freedom from an unproductive or destructive behavior.

Figure 2-4 describes how an individually focused group might respond to the conflict described in Figure 2-3 .

Figure 2-4. Joe’s Case in an Individually Focused Group

The group leader in an individually focused group might work first with Joe and then Jane (or vice versa, depending on who seemed to have the more pressing issues). The group leader might ask Joe to tell the group more about his anger and how he experiences it and might ask him to say why he has difficulty trusting his roommate. Joe could be urged to see how this situation might relate to other circumstances and how his reaction to his roommate’s substance abuse might help him understand his own problems with drinking. The leader might use role‐playing techniques with Joe so that he can practice how he will interact with his roommate and better understand his reaction to his roommate’s behavior. Jane might be asked why Joe’s reaction to his roommate made her so angry. The group leader could try to help her see if Joe reminded her of anyone and whether she identified with the roommate because she too had been judged. Her fears of being judged might be related to her own substance abuse, and the group could explore that possibility.
Source: Adapted from Flores 1997.

Interpersonally focused groups

Interpersonally focused groups generally work from a theory of interactional group therapy, most often associated with the work of Irving Yalom (1995). Other examples of this model of group include sensitivity training, or T‐groups (Bradford et al. 1964), and L. Ormont’s Modern Analytic Approach (Ormont 1992). In groups that follow this model, emphasis is placed primarily on current interactions occurring between and among group members. Clients are urged to explore how they behave, how this behavior affects others, and how others’ behavior affects them.

In interpersonally focused groups, the group leader serves as a role model, but does not explicitly assess the clients’ behavior. That task is left to other group members, who evaluate each other’s behavior. The group leader monitors the way clients relate to one another, and reinforces therapeutic group norms, such as members responding to each other in an emphatic way. The leader also steps in to extinguish contratherapeutic norms that might damage group cohesion or to point out behavior that could inhibit empathic relationships within the group.

Figure 2-5 describes how an interpersonally focused group might respond to the conflict described in Figure 2-3 .

Figure 2-5. Joe’s Case in an Interpersonally Focused Group

A group leader working from an interpersonally focused group model would direct the group’s attention to what is going on between Joe and Jane. The leader might ask Jane if she can tell Joe directly how his statements have made her feel, and then ask Joe to say how he feels about what she said. The group leader might also ask Joe if he sees any parallel in his response to both his roommate and Jane. The leader might ask him if Jane could have reported what she felt in a way that would make him feel less defensive. Jane might tell Joe that she is reacting to his judgmental behavior toward his roommate and his evasiveness about his own drinking. This interaction confronts Joe’s denial. If Jane discloses the reasons behind her response to Joe, namely that her husband distrusts her in a similar manner, the group leader would turn the issue over to the group, perhaps asking Jane how she thinks Joe feels about her. Another group member who has worked on issues concerning trust may interpret what is really going on between Joe and Jane. The goal is to help Joe and Jane deal authentically and realistically with one another, and strengthen the attachment between them. This analysis of relationships within the group may ultimately transfer to settings outside the group and improve Joe’s and Jane’s relationships with others outside the group.
Source: Adapted from Flores 1997.

Group‐as‐a‐whole focused groups

The theoretical approaches most often associated with the group‐as‐a‐whole orientation are Tavistock’s Group‐as‐a‐Whole (Bion 1961; Rice 1965), Agazarian Systems‐Centered Therapy for Group (Agazarian 1992), Bion’s primary assumption groups (Bion 1961), and the focal conflict model (Whitaker and Lieberman 1965). As the name suggests, in this model, the group leader focuses on the group as a single entity or system. While model variations may recognize the group as an aggregate of individuals (the Systems‐Centered Therapy does, for instance), the emphasis remains on the group as a single unit with its own ways of operating in the world.

This model generally is inappropriate for clients with substance use disorders—at least as the sole approach to treatment. It can be harmful, especially to clients new to recovery, and can add to their problems without helping them manage their substance abuse. Certain techniques taken from this approach, however, may be used productively in an eclectic treatment group. For example, when the entire group seems to be sharing a mood, behavior, or viewpoint, a group leader may choose to use mass group process comments, such as “You all seem quiet today” or “Almost everyone is ganging up on Jim.”

Figure 2-6 describes how a group‐as‐a‐whole focused group might handle Joe’s problem.

Figure 2-6. Joe’s Case in a Group‐As‐A‐Whole Focused Group

A group leader with a Bion orientation would notice a lot of conflict swirling around this incident and that the group is in a “fight mode.” The point of interest would be the source of the tension and how it interferes with the work of the group, which is the recovery process. The leader might note that the group has become very involved in this discussion as a way of evading issues of trust common to the whole group. Is the group perhaps fleeing from dealing directly with trust? Looking at Jane’s response, the group leader would consider whether Jane’s response is carrying something for the group, that is, representing a group concern about whether the group will judge members for what they have to say. The discussion might be redirected toward how the group is coping with feelings of uncertainty about continued substance use.
Source: Adapted from Flores 1997.

Three cautionary notes

These vignettes illustrate the different interventions available. No single approach necessarily is more appropriate than any other. The critical question is always, “Is this approach the most likely to succeed with this particular group in substance abuse treatment?”

In addition to making the right strategic choice of approach, the interventions should be done at the right time. Treatment as a time‐dependent process should be the guiding principle when working with people with addictions in group.

Finally, what works for the client without addictions will not always work with a client with addictions. Consequently, the rest of this TIP will be dedicated to exploring the modifications in group technique that need to be made when treating people with substance use disorders.

Specialized Groups in Substance Abuse Treatment

A variety of therapeutic groups that do not fit in the already‐described group models may be employed in substance abuse treatment settings. Some of these specialized groups are unique to substance abuse treatment (like relapse prevention), and others are unique in format, group membership, or structure (such as culturally specific groups and expressive therapy groups). It would be impossible to describe all of the types of special groups that might be used in substance abuse treatment. The three that follow represent a cross‐section of special groups.

Relapse Prevention

Relapse prevention groups focus on helping a client maintain abstinence or recover from relapse. This kind of group is appropriate for clients who have attained abstinence, but who have not necessarily established a proven track record indicating they have all the skills to maintain a drug‐free state. Relapse prevention also can be helpful for people in crisis or who are in some way susceptible to a return to substance use.

Purpose. Relapse prevention groups help clients maintain their sobriety by providing them with the skills and knowledge to “anticipate, identify, and manage high‐risk situations” that lead to relapse into substance use “while also making security preparations for their future by striving for broader life balance” (Dimeff and Marlatt 1995, p. 176). Thus, relapse prevention is a double‐level initiative. It aims both to upgrade a client’s ability to manage risky situations and to stabilize a client’s lifestyle through changes in behavior (Dimeff and Marlatt 1995).

Principal characteristics. Relapse prevention groups focus on activities, problemsolving, and skills‐building. They also may take the form of psychotherapy. For instance, Khantzian et al. (1992) assert that, because the same traits in personality and character predispose people to use substances initially and to relapse during recovery, psychodynamic approaches can mitigate psychological vulnerabilities. Because relapse prevention groups may use techniques drawn from all of these types of groups, they are considered a special type of group in this TIP.

The different models for relapse prevention groups (Donovan and Chaney 1985) include those developed by Annis and Davis (1988), Daley (1989), Gorski and Miller (1982), and Marlatt (1982). All of these models are derived from principles of cognitive therapy. Some, such as that of Marlatt, classify relapse prevention as a form of skills development; other models tend to emphasize support.

These approaches share a number of basic elements, including teaching clients to recognize high‐risk situations that may lead to relapse, preparing them to meet those high‐risk situations, and helping them develop balance and alternative ways of coping with stressful situations. Many of these approaches also increase group members’ feelings of self‐control, so they feel capable of resisting relapse. (More information on the techniques of relapse prevention appears in TIP 34, Brief Interventions and Brief Therapies for Substance Abuse [CSAT 1999a].)

Research has demonstrated that relapse is common and to be expected during the process of recovery (Project MATCH 1997). In a meta‐analysis of 24 controlled clinical trials evaluating relapse prevention programs delivered in both group and individual formats, Carroll (1996) found that relapse prevention groups were effective in comparison to no‐treatment controls for many substances of abuse; the groups were most effective for smoking cessation. Carroll also notes that relapse prevention groups seem to reduce the intensity of relapse when it occurs. Groups also appear to be more effective than other approaches for clients who have “more severe levels of substance use, greater levels of negative affect, and greater perceived deficits in coping skills” (1996, p. 52).

Research also suggests that relapse prevention can be conducted in both group and one‐on‐one formats, with little measurable difference in outcomes. Schmitz and colleagues (1997) compared relapse prevention for cocaine abuse delivered in group and individual formats. Both demonstrated favorable outcomes; no significant difference was detected in cocaine use as measured by urine tests. Clients treated in groups, however, reported fewer cocaine‐related problems than those treated in individual sessions. Further, McKay et al. (1997) found that 6 months after intensive outpatient treatment for cocaine abuse, subjects treated in a group setting displayed higher rates of sustained abstinence than those treated individually.

Relapse prevention carried out in group settings enables clients to explore the problems of daily life and recovery together and to work collaboratively to isolate and overcome problems. Because of these dual goals, relapse prevention groups may improve clients’ quality of life. However, as Schmitz and colleagues note, it may also be the case that the group experience makes members less willing to report the severity of their problems or cause them to feel that their problems are less severe by comparison to those of others (Schmitz et al. 1997).

Leadership skills and styles. Leaders of relapse prevention groups need to have a set of skills similar to those needed for a skills development group. However, they also need experience working in relapse prevention, which requires specialized training, perhaps in a particular model of relapse prevention. Leaders also need a well‐developed ability to work on group process issues.

Group leaders need to be able to monitor client participation to determine risk for relapse, to perceive signs of environmental stress, and to know when a client needs a particular intervention. Above all, group leaders should know how to handle relapse and help the group process such an event in a nonjudgmental, nonpunitive way—clients, after all, need to feel safe in the group and in their recovery. Leaders should know how to help the group manage the abstinence violation effect, in which a single lapse leads to a major recurrence of the addiction.

Additionally, the leader of a relapse prevention group should understand the range of consequences a client faces because of relapse. These consequences can be culturally specific responses, criminal justice penalties, child protective services actions, welfare‐to‐work setbacks, and so on. The group leader, like any counselor, should know the confidentiality rules (42 C.F.R. Part 2) and the legal reporting requirements relating to client relapse.

Techniques. Relapse prevention groups draw on techniques used in a variety of other types of groups, especially the cognitive–behavioral, psychoeducational, skills development, and process‐oriented groups. Because the purpose of a relapse prevention group is to help members develop new ways of living and relating to others, thereby undercutting the need to return to substance use or abuse, potential group members need to achieve a period of abstinence before joining a relapse prevention group.

Communal and Culturally Specific Groups

Restoring lost cultural ties or providing a sense of cultural belonging can be a powerful therapeutic force in substance abuse treatment, and in important ways, substance abuse is intimately intertwined with the cultural context in which it occurs. Cultural prohibitions against substance use and cultural patterns of permissible use define, in part, what is reasonable use and what is abuse of substances (Westermeyer 1995). Risk factors such as cultural displacement or discrimination can cause substance abuse rates to rise drastically for a given population. Problems that pervade particular cultures, such as racism, poverty, and unemployment, have an impact on the incidence of substance abuse and are appropriate focuses for intervention in substance abuse treatment (Taylor and Jackson 1990; Thornton and Carter 1988).

Communal and culturally specific wellness activities and groups include a wide range of activities that use a specific culture’s healing practices and adjust therapy to cultural values. For instance, Hispanics/Latinos generally share a value of personalismo, a preference for person‐to‐person contact. Effective substance abuse treatment providers thus build personal relationships with clients before turning to the tasks of treatment. Also, at the outset of treatment, personal relationships do not yet exist. At this point, a client’s hesitation should not be mistaken for resistance (Millan and Ivory 1994).

Three common ways to integrate such strengths‐focused activities into a substance abuse treatment program are

  • Culturally specific group wellness activities may be used in a treatment program to help clients heal from substance abuse and problems related to it.
  • Culturally specific practices or concepts can be integrated into a therapeutic group to instruct clients or assist them in some aspect of recovery. For example, a psychoeducational group formed to help clients develop a balance in their lives might use an American Indian medicine wheel diagram or the seven principles of Kwanzaa. The medicine wheel represents four dimensions of wellness: belonging, independence, mastery, and generosity. These four concepts promote wellness for the individual and collective good of the American‐Indian tribal group and humanity/environments. Kwanzaa is based on a value system of seven principles called the Nguzo Saba. The Kwanzaa paradigm is a nonreligious, nonheroic ritual that has been widely embraced by the national African‐American community. The Nguzo Saba and other Kwanzaa symbols and practices can be used therapeutically in the regrounding and reconnecting process for African‐American clients.
  • Culturally or community‐specific treatment groups may be developed within a services program or in a substance abuse treatment program serving a heterogeneous population with a significant minority population of a specific type. Examples might include a group for people with cognitive disabilities, or a bilingual group for recent immigrants. Such groups typically are process‐ or support‐oriented, though they also may have psychoeducational components. The groups help minority group members understand their own background, cope with prejudice, and resolve other problems related to minority status. Groups described in this TIP fall into this category.

Purpose. Groups and practices that accentuate cultural affinity help curtail substance abuse by using a particular culture’s healing practices and tapping into the healing power of a communal and cultural heritage. Many have commented on the usefulness of these types of groups (Trepper et al. 1997; Westermeyer 1995), and clinical experience supports their utility. As this TIP is written, little research‐based evidence has accumulated to confirm the effectiveness of this approach. Research is needed to evaluate the effectiveness of culturally specific groups and ascertain the primary indications for their use.

Principal characteristics. Different cultures have developed their own views of what constitutes a healthy and happy life. These ideas may prove more relevant and understandable to members of a minority culture than do the values of the dominant culture, which sometimes can alienate rather than heal. All cultures also have specific processes for promoting wellness among their members.

In using a culture’s healing practices or group activities, whether in heterogeneous or homogeneous groups (that is, all one culture or a mix of cultures), treatment providers should be careful to show respect for the culture and its healing practices. As long as respect and awareness are evident, the use of such practices will not harm the members of a particular culture.

Leadership characteristics and style. Group leaders always need to strive to be culturally competent with members of the various populations who enter their programs.1 Substance abuse treatment counselors first need to be aware of the demographics in their program areas, and to be aware as well that there are many people from mixed ethnic backgrounds who do not necessarily know or recognize their cultural heritage. Clinicians should actively avoid stereotyping clients based on their looks, and instead allow them to self‐identify. Clients should be asked what it means to them to belong to a particular group. Clinicians also should be sensitive to self‐identification issues such as sexual orientation, gender identification, and disability. When in doubt, clinicians should discuss the issue privately with the client.

A group leader for a culturally specific group will need to be sensitive and creative. How much authority leaders will exercise and how interactive they will be depends on the values and practices of the cultural group. The group leader should pay attention to a number of factors, all of which should be considered in any group but which will be particularly important in culturally specific groups. Clinicians should

  • Be aware of cultural attitudes and resistances toward groups.
  • Understand the dominant culture’s view of the cultural group or community and how that affects members of the group.
  • Be able to validate and acknowledge past and current oppression, with a goal of helping to empower group members.
  • Be aware of a cultural group’s collective grief and anger and how it can affect countertransference issues.
  • Focus on what is held in common among members of the group, being sensitive to differences.

The SageWind Model for group therapy, discussed in Figure 2-7 , provides individually tailored interventions for its clients.

Figure 2-7. The SageWind Model for Group Therapy

In programs that have the resources, the capacity to offer a variety of types of groups addressing a range of client needs is preferred. SageWind in Reno, Nevada, offers more than 100 groups each week.
To assess each client’s unique needs, SageWind’s comprehensive biopsychosocial assessment evaluates the severity of a client’s substance abuse. In addition, the clinical team, the client, and any others concerned (such as probation or parole officers, parents or legal guardians, or social workers) determine the best course of group therapy formats.
Group intervention ranges in intensity from one group per week to more than 20. The large number of weekly groups offered in SageWind’s menu of options covers a continuum of treatment options from psychoeducational to skills‐building to experiential to process‐oriented. In a structured program similar to that of a university, where fundamental courses are required before more advanced ones may be taken, clients attend the groups they need, then change to others and progress through the program. Clients complete groups, moving to more advanced formats until they have met discharge criteria based on the American Society of Addiction Medicine (ASAM) Patient Placement Criteria‐2R (PPC‐2R) (ASAM 2001).

Techniques. Different cultures have specific activities that can be used in a treatment setting. Some common elements in treatment include storytelling, rituals and religious practices, holiday celebrations, retreats, and rites of passage practice (these may be particularly useful for adolescent clients).

Culturally specific groups work best if all members of the population become involved in the activity, even the clients who are not familiar with their cultural heritage. In fact, the reasons for that lack of familiarity can become a topic of discussion. Helping clients understand what they have lost by being separated from their cultural heritage, whether because of substance abuse or societal forces, can provide one more reason to continue in sobriety.

Expressive Groups

This category includes a range of therapeutic activities that allow clients to express feelings and thoughts—conscious or unconscious—that they might have difficulty communicating with spoken words alone.

Purpose. Expressive therapy groups generally foster social interaction among group members as they engage either together or independently in a creative activity. These groups therefore can improve socialization and the development of creative interests. Further, by enabling clients to express themselves in ways they might not be able to in traditional talking therapies, expressive therapies can help clients explore their substance abuse, its origins, the effect it has had on their lives, and new options for coping. These groups can also help clients resolve trauma (like child abuse or domestic violence) that may have been a progenitor of their substance abuse. For example, Glover (1999) states that play therapy and art therapy are particularly useful for substance abuse treatment clients who have been incest victims. Play and art therapies enable these clients to work through their trauma and substance abuse issues using alternatives to verbal communication (Glover 1999).

Although a number of articles have theorized about the usefulness of various types of expressive therapy for clients with substance use disorders, little study on the subject has used rigorous research methods. Clinical observation, however, has suggested benefits for female clients involved in dance therapy (Goodison and Schafer 1999). Client self‐reports suggest the value of psychodrama for female clients in treatment for alcoholism, particularly for highly educated women and those who are inclined to be extroverted and verbally expressive (Loughlin 1992).

As Galanter and colleagues note, expressive therapy groups—which they called “activity groups”—often can be “the source of valuable insight into patients’ deficits and assets, both of which may go undetected by treatment staff members concerned with more narrowly focused treatment interventions” (Galanter et al. 1998, p. 528).

Principal characteristics. The actual characteristics of an expressive therapy group will depend on the form of expression clients are asked to use. Expressive therapy may use art, music, drama, psychodrama, Gestalt, bioenergetics, psychomotor, games, dance, free movement, or poetry.

Leadership characteristics and style. Expressive group leaders generally will have a highly interactive style in group. They will need to focus the group’s attention on creative activities while remaining mindful of group process issues. The leader of an expressive group will need to be trained in the particular modality to be used (for example, art therapy).

Expressive therapies can require highly skilled staff, and, if a program does not have a trained staff person, it may need to hire an outside consultant to provide these services. Any consultant working with the group should be in regular communication with other staff, since expressive activities need to be integrated into the overall program, and group leaders need to know about each client if they are to understand their work in the group.

Expressive therapies can stir up very powerful feelings and memories. The group leader should be able to recognize the signs of reactions to trauma and be able to contain clients’ emotional responses when necessary. Group leaders need to know as well how to help clients obtain the resources they need to work though their powerful emotions.

Finally, it is important to be sensitive to a client’s ability and willingness to participate in an activity. To protect participants who may be in a vulnerable emotional state, the leader should be able to set boundaries for group members’ behavior. For example, in a movement therapy group, participants need to be aware of each other’s personal space and understand what types of touching are not permissible.

Techniques. The techniques used in expressive groups depend on the type of expressive therapy being conducted. Generally, however, these groups set clients to work on an activity. Sometimes clients may work individually, as in the case of painting or drawing. At other times, they may work as a group to perform music. After clients have spent some time working on this activity, the group comes together to discuss the experience and receive feedback from the group leader and each other. In all expressive therapy groups, client participation is a paramount goal. All clients need to be involved in the group activity if the therapy is to exert its full effect.

Groups Focused on Specific Problems

In addition to the five models of therapeutic groups and three specialized types of groups discussed above, groups can be classified by purpose. The problem‐focused group is a specific form of cognitive–behavioral group used to eliminate or modify a single particular problem, such as shyness, loss of a loved one, or substance abuse. In sheer numbers, these groups are the most widespread. Additionally, problemsolving groups are directed from a cognitive–behavioral framework. They focus on problems of daily life for people in early and middle recovery, helping group members learn problemsolving skills, cope with everyday difficulties, and develop the ability to give and receive support in a group setting. As clients discuss problems they face, these problems are generalized to the experience of group members, who offer support and insight.

Purpose. Problem‐focused groups’ primary purpose is to “change, alter, or eliminate a group member’s self‐destructive or self‐defeating target behavior. Such groups are usually short‐term and historically have been used with addictive types of behavior (smoking, eating, taking drugs) as well as when the focus is on symptom reduction…or behavioral rehearsal” (Flores 1997, p. 40).

Principal characteristics. Problem‐focused groups are short (commonly 10 or 12 weeks), highly structured groups of people who share a specific problem. This type of group is not intended to increase client insight, and little or no emphasis is placed on self‐exploration. Instead, the group helps clients develop effective coping mechanisms to enable them to meet social obligations and to initiate recovery from substance abuse. The group’s focus, for the most part, is on one symptom or behavior, and they use the cohesiveness among clients to increase the rate of treatment compliance and change. A problem‐focused group commonly is used in the early stages of recovery to help clients engage in treatment, learn new skills, and commit to sobriety. This kind of group is helpful particularly for new clients; its homogeneity and simple focus help to allay feelings of vulnerability and anxiety.

Leadership characteristics and styles. The group leader usually is active and directive. Interaction within the group is limited typically to exchanges between individual clients and the group leader; the rest of the group acts to confront or support the client according to the leader’s guidance.

Techniques. Many traditional recovery groups fall into the problem‐focused category, which includes abstinence maintenance, relapse prevention, support, behavior management, and many continuing care groups. Other examples are groups that help support people with a specific problem or loss (such as breast cancer or suicide in the family), help people alter a particular behavior or trait (like overeating or shyness), or learn a new skill or behavior (for instance, conflict resolution or assertiveness training).

In practice, group leaders may use different models at various times, and may simultaneously influence more than one focus level at a time. For example, a group that focuses on changing the individual will also have an impact on the group’s interpersonal relations and the group‐as‐a‐whole. Groups will, however, have a general orientation that determines the focus the majority of the time. This focus is an entry point for the group leader, helping to provide direction when working with the group.

When deciding on a model for a substance abuse treatment group, programs will need to consider their resources, the training and theoretical orientation of group leaders, and the needs and desires of clients in order to determine what approaches are feasible. The reader may also refer to appendix B of TIP 34, Brief Interventions and Brief Therapies for Substance Abuse (CSAT 1999a ), for a list of resources that can provide further training and information about the theoretical orientations that influence these groups.

Footnotes

See chapter 3 of this TIP and the forthcoming TIP Improving Cultural Competence in Substance Abuse Treatment (CSAT in development a) for more information on cultural competence. TIP 29, Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities (CSAT 1998b ), contains information on being sensitive and responsive to the needs of people with disabilities, and A Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals (CSAT 2001) has information on working with gay and lesbian populations.

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